Med-surg FINAL EXAM 2023 Answered 100% Correct (100 Q&A)

Med-surg FINAL EXAM 2023 Answered 100% Correct (100 Q&A)

1. A client with a diagnosis of disseminated intravascular coagulation (DIC) has the following assessment findings: blood pressure of 76/56, temperature 102.6 degrees, resp. 24 breath/min., with complaints of severe neck and back pain. Which nursing action should the nurse implement first?

a. Administer acetaminophen (Tylenol) PO.

b. Administer ibuprofen (Motrin) PO.

c. Draw coagulation study blood work in the AM

d. Give morphine sulfate IV {{Correct Ans- a.Administer acetaminophen (Tylenol) PO.

2. The nurse administering albuterol (Proventil) via a metered-dose inhaler (MDI) to a client who has a history of coronary artery disease is now in congestive heart failure. What side effects will be particularly important to observe for when the client takes the medication?

a. Tremors and central nervous system stimulation

b. Tachycardia and chest discomfort

c. Development of oral candidiasis

d. An increase in blood pressure {{Correct Ans- a.Tremors and central nervous system stimulation

3. The nurse is assessing a client who is on a ventilator and has an endotracheal tube in place. What data confirms that the tube has migrated too far into the trachea?

a. Decreased breath sounds are heard over the left side of the chest

b. Increased rhonchi are present at the lung bases bilaterally

c. Ventilator pressure alarm continues to sound

d. Client is able to speak and coughs excessively {{Correct Ans- a. Decreased breath sounds are heard over the left side of the chest

4. What is the desired action of dopamine (Intropin) when administered in the treatment of shock?

a.It increases myocardial contractility

b. It is associated with fewer severe allergic reactions

c. It causes rapid vasodilation of the vascular bed

d. It supports renal perfusion by dilation of the renal arteries {{Correct Ans- a.It increases myocardial contractility

5. The nurse is monitoring an IV infusion of sodium nitroprusside (Nirpride). Fifteen minutes after the infusion is started, the client's BP goes from 190/120 mm Hg to 120/90 mm Hg. What is the priority nursing action?

a. Recheck the BP and call the doctor

b. Decrease the infusion rate and recheck the blood pressure in 5 minutes

c. Stop the medication and keep the IV open with D5W.

d. Assess the client's tolerance of the current level of BP {{Correct Ans- b. Decrease the infusion rate and recheck the blood pressure in 5 minutes

6. Norepinephrine (Levophed) has been ordered for a client in hypovolemic shock. Before administering the drug, the nurse should make sure that the client has:

a. A heart rate of less than 120 beats/min

b. Urine output of at least 30 mL/hr.

c. Received adequate anticoagulation

d. Been receiving adequate IV fluid replacement {{Correct Ans- d. Been receiving adequate IV fluid replacement

7. The client returns to his room after a thoracotomy. What will the nursing assessment reveal if hypovolemia from excessive blood loss is present?

a. CVP of 3 cm H20 and urine output of 20 mL/hr

b. Jugular vein distention with the head elevated 45 degrees

c. Chest tube drainage of 50 mL/hr in the first 2 hours

d. Persistent increased BP and increased pulse pressure {{Correct Ans- a. CVP of 3 cm H20 and urine output of 20 mL/hr